Tag Archives: knowledge translation

Low Back Pain: Physician Paradigm Shifts and the Doctor of Physical Therapy

What do the common cold and low back pain (LBP) have in common? They are the top 2 symptomatic reasons for primary care visits in the United States (US) [1, 2].

In 1998, total US health care costs for LBP were approximately $90 billion [3, 4]. Musculoskeletal (MSK) conditions account for roughly 25% of patient complaints in the primary care setting [5, 6].

In the emergency department (ED), MSK dysfunction accounts for 20% of all chief complaints with 2.7 million visits specifically devoted to LBP [7]. In fact, MSK conditions rank second only to respiratory illness with respect to prevalence of most common presentations in the ED[8].

The intent of this article is to identify global systematic weaknesses in medical education while discussing implementation of best practices as it pertains to low back pain intervention.

My hopes are that by exposing the physician to potential clinical decision and behavioral paradigm shifts that can be immediately implemented, we can reduce cost, increase efficiency, and make our patients feel better quicker.

One thing is for sure: I bet you didn’t learn this in Medical School…

II. Physician Confidence and Competence of MSK Conditions:

It has been recently cited that newly graduated medical students and residents lack the clinical knowledge and confidence necessary to care for patients with MSK injuries. Deficiencies have been shown at all levels of training from medical student to attending [8-11].

Approximately 50% of family practice physicians feel inadequately trained in MSK medicine [8, 12]. There have been similar numbers reported amongst the emergency physician with marked deficiencies in musculoskeletal education ranging from trainees to attending staff[8].

As exposure to MSK conditions increase and physician confidence remains low, we need to address this dilemma head on.

Identification and efforts to improve quality of MSK exposure and future physician education is presently being reviewed and developed[11].

What happens to present day practice in the mean time?

Allow me to take you down a paradigm shift in thinking for the present day physician as it pertains to patient access and prescriptive intervention.

CPG’s have been copiously produced in an effort to guide a broad range of clinicians along a mutually agreed upon diagnostic pathway. In conjunction with the Choosing Wisely campaign, CPGs combined with 2 of the 3 central tenets of Evidence Based Medicine, doctors should be prescribing fiscally responsible and safe interventions for our patients.

Unfortunately, this isn’t always the case.

There continues to be overuse of imaging in the emergency and primary care setting despite evidence based recommendations from the American College of Physicians,American Pain Society[4, 13], and the Choosing Wisely Campaign[14].

These organizations call for lumbar spine imaging only for patients who have severe or progressive neurologic deficits or signs and symptoms that suggest a serious or specific underlying condition[13].

Another example of physician knowledge translation failure occurs with the Ottawa Foot and Ankle Rules (OFARs). In a 2014 study of emergency physician application of the OFARs, there was no statistical evidence that application of the OFARs decreases the number of imaging orders.In fact 58 of the 60 patients that qualified under the OFARs were imaged [15]. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

Unlike the foot and ankle complex, pathoanatomic diagnoses in the lumbar spine is often more detrimental to clinically relevant patient care than not.

Excessive spinal imaging can lead to downstream pathways that can lead to instilling fear of the unknown or “too-much known” into the patient, unnecessary invasive interventions, time lost from work, familial, and social life, and the fiscal burden that all of the above places on government, third-party and private payers.

Savage et al[20]reported that 32% of their asymptomatic subjects had “abnormal” lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression) and only 47% of their subjects who were experiencing low back pain had an abnormality identified[19, 20].

Pathoanatomic abnormalities are so common in the asymptomatic individual it should be viewed as a normal sign of aging with present day knowledge of MSK advanced imaging.

As it pertains to the geriatric population, a cross- sectional study revealed[17] 36% of asymptomatic persons aged 60 years or older had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc [4, 17].

With 22% of the population about to cross over into the geriatric cohort, are we going to continue to expose our patients to undue radiation, opioids and costly-clinically irrelevant tests?

IV: Knowledge Translation Gaps due to…?

Minimal exposure to musculoskeletal education in medical school has previously been highlighted as a significant issue in both North America and the United Kingdom[8, 21-27].

Over the years, my physician friends and colleagues, international and domestic, have congruently agreed upon one common theme amongst their MD/DO medical education: a paucity of MSK learning opportunities during their formative years in medical school and residency training[11].

I’m fortunate to surround myself with people who are as equally as enthusiastic and curious with respect to medical learning.

My small conversational sample size over the years finally took me to the literature.

V. The Literature:

As the geriatric population continues to grow exponentially, there is an $848 billion annual fiscal estimate for treatment, diagnosis, and lost wage amounting to ~7.7% of the gross domestic product for MSK chief complaints [11, 28].

In 2030, the pediatric and geriatric population will account for 21% and 22% of our population due to the baby boomer surge[29].

Think about this for a moment. There will be more people 65 years and older than 17 years old and under.

As the geriatric population continues to stay active and educated, MSK conditions of all age cohorts are going to skyrocket. More severe forms of LBP increase with age with overall prevalence increasing until ages 60-65[19, 30, 31].

In a 2010 national study on LBP and diagnostic testing in the ED, imaging was performed in nearly 50% of all LBP patients and opioids were administered to nearly 2/3’s of the sample[7].

Emergency Medicine physician Judith Tintenalli, stated that we need increased “efforts to change consumer behaviors” with respect to patient access and referral to the ED. It has been cited that up to 43% of direct access ED visits are deemed unnecessary. When referred by a PCP, up to 44% of those referrals were also deemed inappropriate. [32]

A modification of the Tintenalli statement would be we need increased efforts to change consumer and clinician behaviors. Clearly patients and providers are both lacking awareness of who should be utilizing ED skilled clinical services for MSK conditions.

With rates of chronicity related to an episode of LBP increasing [2], there needs to be a significant shift in intervention and clinical decision making for patients of all ages.

Change in behavior, intervention, and clinical decision making?

What else is there besides the physician ordered image, oral medication, invasive procedure and surgery?

VI. The role of the Non-Physician Doctor in Modern Day MSK Management:

Experienced doctors of physical therapy have higher levels of knowledge in managing musculoskeletal conditions than all physician specialists except for orthopedists [6]. This includes medical students, physician interns, residents, and attending physicians.

I know that piece of information was not imparted on you in medical school.

Allow me to provide some high-yield clinical pearls that will hopefully expand your breadth and depth of knowledge as it pertains to low back pain and your patients.

Who is the present day Doctor of Physical Therapy (DPT)?

Simply stated, DPTs are body mechanics. Our sole purpose is to make people move and interact with their environment in the most energy efficient, symptom free, safe, and functional way.

DPTs are skilled doctoral degree level clinicians with core knowledge of all systems to allow us to appropriately screen and differentially diagnose all patients that we come in contact with for evaluation and treatment. Similar to the traditional medical model, we have intensive board specialities in cardiology, orthopedics, sport, geriatrics, pediatrics, neurology and hand. Residency and fellowship are also becoming more prevalent with ~2,500 DPT’s trained in residency or fellowship from 1999-2013[33].

Accessed: www.abptrfe.org/Home.aspx

As of January 2015, all 50 states will have direct access to DPT’s. This means that a prescription is no longer required to access our care for the MSK patient.

Image: http://webreprints.djreprints.com/1715540469703.html

Direct access privileges have been present in the US Army for over 40 years. In fact, Army DPT’s are able to order imaging and administer medication as necessary.

A retrospective analysis of 472, 013 patient visits at 25 military healthcare sites, 45.1% of the visits were determined to be patients with direct access and without physician referral. No adverse events were determined from either physical therapy diagnosis or management [34].

What does direct access mean for the civilian population?

Simply stated: autonomy.

This means that patients can have instant access to a DPT as soon as they have MSK pain or dysfunction. We’ve accepted the role of greater diagnostic responsibility by achieving the clinical rigors of a doctoral education; this autonomy doesn’t mean we stop communicating with the medical community. DPT’s have worked hard to achieve autonomous practice. Working and communicating with the physician, physician assistant (PA-C), and Nurse Practitioner (NP) are still priority as our profession tends to lead the way in collective competence as we learn to adapt to today’s healthcare systems.

Pathoanatomic diagnoses are no longer the gold standard for diagnosis and treatment of patients with acute, subacute or chronic LBP. Factually, this is why many LBP studies failed to achieve anything substantial, measurable and remarkable over the last two decades (see false positive and true negative rates above).

Presently, there has been some excellent work done by Fritz[36-38], Childs[6, 39], and Delitto[19] working on sub-grouping LBP patients. If you choose to do any interdisciplinary reading these are the articles you should be reading to expand your knowledge base.

The development of classification systems has been identified as a priority among researchers in the primary care management of patients with low back pain[19, 40].

An entirely separate article can be devoted to sub-groups and treatment based classification systems; however, for immediate knowledge translation integration, I’ve identified four of the subgroups for you below.

Treatment based classification systems use an in depth history, mechanism of injury, and physical examination. They include 1. mobilization, 2. specific exercise, 3. immobilization, and 4. traction subgroups [19].

We know that LBP is not a homogenous entity, therefore, we need to identify, triage, and treat these patients differently depending on where they are along the spectrum of their dysfunction and pain episode.

Every subspecialty in healthcare is going to come in contact with a LBP patient due to the incidence, prevalence, and potential debilitating nature of the injury.

Now is the time to think differently. Now is the time to stop putting the square peg in the round hole.

In a landmark study by Daker-White et al in 1999[41],a randomized controlled trial was done comparing care of patients solely seen by the physician v. the PT.Entitled, Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments, 244 patients were seen by a post-fellowship physician and 237 patients were seen by a physical therapist.

There is a scarcity of dually trained specialty board certified, residency, and/or fellowship trained doctors of physical therapy in the US; however, we do exist and there are more and more physical therapists pursuing doctoral level degrees, speciality certification, and advanced training every year.

There needs to be a healthy interaction, rapport building and conversation amongst the physician and DPT in the #MedEd community. We need your presence for prescriptive intervention for the biochemistry needs and red flags that can occur with this patient population just as much as there is a need for a paradigm shift in prescriptive, existing clinical decision making, and intervention as it pertains to the LBP patient.

Doctors of Physical Therapy have slowly been introduced to the emergency medicine team and thus far with great success[42]. As this trend continues to grow, a more immediate solution needs to occur.

All 50 states in the US will have direct access to physical therapy services in January of 2015. Now is the time to refer that patient directly to the orthopedic physical therapy office (with or without prescription) so we can decrease unnecessary ED visits leading to opioid prescriptions, imaging, and other prescriptive screening tools leading to costly downstream clinically irrelevant interventions.

Use us. No, really. Use us.

Let us safely screen and differential this cohort of patients. Most of the time they need reassurance that they will be ok and we can provide them with the screening tools to differentially diagnose and refer out to the proper physician as needed.

Most important to the patient, we can make them feel better-if not physically, psychologically usually within the first visit in order to decrease fear-avoidance behaviors[37].

Providing patient education on positioning for comfort, relief and functional positioning for their activities of daily living while utilizing our manual therapy skills to massage, mobilize, manipulate, therapeutically exercise, or stretch this population of patient is key to successful clinically relevant outcomes.

Remember, the LBP patient is not a homogenous entity and neither is their interventional prescription. Let us identify their sub-group based off of treatment based classifications and safely intervene right away (ideally within the first two weeks).

I hope this review provided some new and thought provoking ideas that will hopefully plant the seed for you to share this blog with a fellow colleague, look further in to the literature, and expand the breadth and depth of your MSK knowledge base.

My name is Dr. Jessica Schwartz. I am a residency trained Doctor of Physical Therapy. How can I assist you and your patient’s needs today?

Quick Points:

1. Physician, PA-C, and NP colleagues #ThinkDifferent and take a pause in your clinical decision thought processes when encountering your next low back pain patient. Do you know a PT that you trust and can directly refer to? Now you have excellent conversational tools to engage in a conversation in an interdisciplinary way to best suit the patients needs.

2. PT’s in the United States will have direct access in all 50 states starting January 2015. This means a patient does not need a prescription to access our services. This can be for an acute, subacute, and chronic condition. Allow us to differentially screen and refer out as needed. See the American Physical Therapy Association (APTA) Overview.

3. Use this article to expand the breadth and depth of your MSK knowledge base when speaking with fellow colleagues. Think beyond the opioid, radiographic image, and the “wait and see approach”. Take action within the first 14 days of an acute episode and be participative in your patients intervention

4. To my international colleagues, please use this article to engage in conversation. I’ve already learned so much from interdisciplinary conversation after publishing this article. Question medicine…always. Engagement is how we learn and continue to grow. Cheers to you!

13. Chou, R., et al., Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med, 2007. 147: p. 478-491.

14. Choosing Wisely: An Initiative of the ABIM Foundation.[cited 2014 December 21, 2014]; Available from: http://choosingwisely.org/.

15. Ashurst, J.V., et al., Effect of triage-based use of the Ottawa foot and ankle rules on the number of orders for radiographic imaging. J Am Osteopath Assoc, 2014. 114(12): p. 890-7.

20. Savage, R.A., G.H. Whitehouse, and N. Roberts, The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J, 1997. 6(106-114).

Social Media and Medicine (#SoMe): How to Use Technology to Increase Knowledge Translation and Self-Directed Learning Processes

History Behind Article:

We’re clinicians that live and practice in exponentially different ways with one seemingly universal commonality: We’re busy.

Factually, we lose attention and retention with initial memory formation between 20-40 minutes via axonal projections from the hippocampus to the cerebral neo-cortex [1]. Learning requires modification from some of the most basic synaptic interfaces at the dendritic level. The dynamic nature of these dendritic spines are important for neuro plasticity and our ability to take on new information [2].

After formal education and residency, we are expected to remain clinically competent and synaptically sharp in a world inundated with information, tasks, and projects. I have earned the title of Doctor- now how do I maintain this perceived clinical acuity and sharpness that my peers and patients expect of me independently?

In graduate school and residency we’re handed information. It is easy to take for granted the work and effort it takes to be caught up on the latest research and trends in medicine. More importantly, how to stay passionate while minimizing frustration levels with streamlining and accessing seemingly endless amounts of information. What’s relevant? Did I just waste 20 minutes reading an article that was pointless?

As stated in my original blog post, I hope to share my passion and authentic curiosity for medicine as well as facilitate passionate conversation with the intention of creating better clinicians and self-directed learners.

In an effort to guide you through my process, I will share the educational, social media and research pearls that have set me up for success and kept my synapses firing in 2014.

What To Expect:

At any given time we have an abundance of external distractions inundating us with pings, alerts, scrolls, vibrations, etc. I’m fairly certain in grad-school, I answered my remote control working on my thesis, quieting my puppy, avoiding Facebook notifications…

Sound familiar???

This leads us to the key question of this article: How do I quiet the external noise and organize myself professionally in order to become a better clinician? (And still lead a socially productive life!)

Below you will find my organizational process incorporating my present (and ever-changing) incorporation of using Social Media and Medicine to increase knowledge translation and self-directed learning processes with the intent of becoming a better doctor.

Feedly

History:

During the 10 years of my formal pedagogical career I asked one question throughout every single college or university I attended: How do you receive new information and organize your research/medical content?

After years of disorganized manilla folders, lost papers, and bookmarks strewn across various web browsers, I learned about Feedly.

Feedly Pearls:

Feedly is a news aggregator with a beautiful User-Interface (UI) for iOS, Android, and your computer that allows you to process, receive, and sift through information in a very intuitive and minimalistic way.

Feedly allows you to organize nearly everything on the internet from peer reviewed journals, podcasts, blogs, news sites, and YouTube Channels in a list, card, or magazine view.

Feedly organizes topics with Categories. Categories are essentially folders if you would like to think about Feedly as a desk with drawers. Take the time to organize your Categories and then add your favorite journals, podcasts, etc.

The beauty of the product is that everything gets delivered to you instead of you having to seek out the information in piece meal. I equate it to going to Blockbuster or the Movie Theater back in the 1990’s and now everything is streamed and filtered to you via NetFlix, Amazon Prime, Hulu, etc via the cloud. I personally take 30-60 minutes on the weekend and sit with a cup of tea on my balcony and sift through incoming information and news streams.

I can sift from 20 to 100’s of different titles scrolling through ~5-10 pieces at a time on my iPhone or iPad (my preferential viewing style). My goals are to move through all of the content that I have in my Categories and get to Zero. Anything I see along the way that interests me, I hit Save For Later. When I get down to Zero, I then go back into my Saved For Later Category and then take the time to meaningfully go through the content that I have found interesting.

Any journal articles, podcasts, or blog posts that I deem worth keeping, I immediately store them in EndNote (see below), my Web-Browser folders or Evernote. If something is too long, I have a “Read Later” folder in both my EndNote and Web-Browser that I sit down with at a later time before I decide if I want to keep said article of interest.

[For cohesive integration of Feedly, Twitter, and Endnote see below]

Screenshot of Feedly on MacBook Air

Screenshots of Feedly on iPhone

Summative Feedly Pearls:

1.Set up your Feedly on your computer

2. Find what you know

3. When you are comfortable, branch out and search broader topics of interest

4. Read and sift through articles on your iPhone/iPad or Android device taking advantage of the excellent UI

5. Work in 20 minute goal oriented time frames

Twitter

History:

There are endless possibilities for how to use Twitter.

My friends in media have used Twitter for years to promote themselves and their brands. It wasn’t until recently that I became aware of a select few of my friends and colleagues using it for medicine. I started noticing that most professional organizations, hospitals, journals and conferences were also on Twitter.

If you don’t enter the space of Twitter cautiously and well planned, it can feel like you are standing on one leg, in New York City traffic, juggling ultrasound heads while trying to catch clinical and educational pearls thrown at you by the medical community…that are lit on fire (i.e.-It can be very intimidating).

The key question is: how can we streamline this and make it efficient so it’s not overwhelming?

The answer is to integrate yourself into Twitter in bite-sized digestible pieces.

Twitter Pearls:

My #1 Twitter Pearl = Create Lists.

Lists allow you to organize people, organizations and topics into smaller cohorts.

For example:

By clicking on myTwitter handle @DPT2Goand clicking on myLists page you can subscribe to anything that I’ve made public (Medical Organizations, PT’s, Rehab Medicine, Medicine, Medical Organizations, Journals, etc). As you create more connections with people whom you follow, you essentially create this entangled web of people, places and organizations that provide you with seemingly unlimited access to experiential or voyeuristic learning opportunities.

It’s O.K. to sit back and not tweet/participate. Saving informational pieces in your Favorites is completely fine. In fact, it took me a few years to start Tweeting!

In an effort to save time searching, you can subscribe to other peoples lists as well.

If you aren’t sure where to start or where to look, I recommend the Symplur Hashtag Project specifically relating to healthcare.

Hashtags group tweets into topics so they can easily be searched later on. Popular hashtags include #PT, #DPT, #MedEd, #FOAMed, #SoMe, #Healthcare, #DPTStudent, #Hospital, etc. Conferences also create hashtags for themselves and change yearly.

Getting overwhelmed with Twitter/Feedly:

Because there are seemingly endless amounts of things on Twitter and Feedly, here are a few suggestions to get you set up efficiently:

4. Work in 20 min increments (See Pomodoro Technique below). It’s easy to get lost for hours syphoning through endless possibilities and connections. And remember, that’s all we really have meaningful attention for anyway…

The more gradual you enter this space of Twitter the higher likelihood of retention, maintaining interest, and knowledge transfer will occur for long term and meaningful use. Process the information at your own pace. Review it. Review it again. And find a process that works specifically for YOU.

An example of how I’ve organized some of my lists below:

Summative Twitter Pearls:

1. Twitter is essentially a microblog that allows you to communicate in 140 character bits of information

2. Create your Twitter Handle keeping the above in mind so people can reply to or include you in Tweets without compromising the 140 character limit

3. Create lists + Organize yourself early

4. Start your search with what you know

5. Branch out and search broader topics when you are comfortable

6. Remember to always be respectful and mindful of your professional presence. Seriously, the Library of Congress archives every single tweet.Read more here if you’re interested

7. Choose to be an educational voyeur or interact and engage with the Twitter community. Either way-Have fun and learn!

EndNote:

History:

Every institution I have been a part of during my educational journey has literally handed out EndNote for free. It is supposed to be the platinum package of commercial reference management software. I literally had hundreds of dollars of software handed over to me during a decade and didn’t use it.

I equate it to being handed a piece of Grade-A organic grass fed steak sans utensils or a means of cooking it. I had NO idea how to use it and the bigger issue early on in education…I didn’t really care to.

As a novice learner, I was literally inundated with so much data that I really only cared to learn to differentially diagnose X and treat Z.

The UI is not the most intuitive and past versions, to be blunt, could’ve been designed by a novice coder. However, they have spruced a few things up at Thomson Reuters to make things more intuitive and useful for the clinician on-the-go.

I am going to discuss EndNote; however, there are a few other notable players in the reference storage, PDF annotation, and citation management game (See Table 1 for comparison).

I continue to stick with EndNote because it’s what I have always used; however, I think Papers 3.0 has some serious potential with respect to cost, UI, and cross-platform access; however, until they can improve on their cloud storage and glitchy updates I’ll continue to use EndNote.

(Table 1: Reference Management Software Comparison)

EndNote Pearls:

Organize EARLY.

I have thousands of articles that I’ve accumulated over the years. I recently started from scratch and began organizing things I need and want in my present library.

Arrange your “My Groups” (similar to Categories in Feedly and Lists in Twitter) on the left part of the screen under My Library

For the most part, EndNote is very intuitive. If importing PDF’s from PubMed, WorldCat, a specific journal you have access, etc- it will migrate most data over for you. There are some instances where it won’t do that.

My advice is manually import the relevant data right away. Bare necessities: Title, Journal, Year, Author(s), Pages, Volume and PubMed ID. The PubMed ID is preferential; however, I would much rather copy and paste “24658701” than a full title, author(s), journal, etc.

The beauty of EndNote X7 is My EndNote Web which allows you to access your files on-the-go complete with annotations, highlights, etc. There are very few times I am without my laptop, however, it does make file access and citation management very easy especially during travel.

Summative EndNote Pearls:

1. Organize and setup groups right away

2. Make sure important data is migrated in with article. If not, do it manually ASAP

3. Annotate and highlight directly in EndNote allowing you to search via My EndNote Web and iPad later

Pomodoro®Timer:

The Pomodoro Technique is a time management method developed in the late 80’s by Francesco Cirillo. Essentially the technique breaks things down in to 25 minute intervals assigned to a task list that you create implementing short breaks in between each ‘Pomodori’.

I use a Pomodoro Timer on my phone. Essentially it is just a fancy timer, but it has helped me immensely with regard to breaking up larger tasks into smaller ones and decreasing distractibility. In other words, I don’t get distracted by email pings, Facebook notifications, Twitter alerts, my dogs, etc while I am working on the task at hand. I simply wait until the 5 minute break allotted to me.

So simple and highly necessary when I am in the middle of a project!

Putting It All Together:

Initially, this can all seem quite daunting; however, I can’t imagine practicing without having integrated social media and technology into my educational process. The initial time and energy spent to organize, integrate and utilize these multiple services early-on will reap tremendous rewards for the you as a self-directed-forever learner.

Good luck in your educational journey and continue to stay hungry, engaged and passionate!